A history of lumbar disc herniation from Hippocrates to the 1990s.

In ancient times, a supernatural understanding of the syndrome of lumbar radiculopathy often involved demonic forces vexing the individual with often crippling pain. The ancient Greeks and Egyptians began to take a more naturalistic view and, critically, suspected a relationship between lumbar spinal pathology and leg symptoms. Relatively little then changed for those with sciatica until the classic works by Cotugno and Kocher arrived in the late 18th century. Early lumbar canal explorations were performed in the late 1800s and early 1900s by MacEwen, Horsley, Krause, Taylor, Dandy, and Cushing, among others. In these cases, when compressive pathologies were found and removed, the lesions typically were (mis-)identified as enchondromas or osteochondritis dissecans. To better understand the history, learn more about the first treatments of lumbar disc herniation, and evaluate the impact of the early influences on modern spine practice, searches of PubMed and Embase were performed using the search terms discectomy, medical history, lumbar spine surgery, herniated disc, herniated nucleus pulposus, sciatica, and lumbar radiculopathy. Additional sources were identified from the reference lists of the reviewed papers. Many older and ancient sources including De Ischiade Nervosa are available in English translations and were used. When full texts were not available, English abstracts were used. The first true, intentional discectomy surgery was performed by Mixter and Barr in 1932. Early on, a transdural approach was favored. In 1938, Love described the intralaminar, extradural approach. His technique, although modified with improved lighting, magnification, and retractors, remains a staple approach to disc herniations today. Other modalities such as chymopapain have been investigated. Some remain a part of the therapeutic armamentarium, whereas others have disappeared. By the 1970s, CT scanning after myelography markedly improved the clinical evaluation of patients with lumbar disc herniation. In this era, use of discectomy surgery increased rapidly. Even patients with very early symptoms were offered surgery. Later work, especially by Weber and Hakelius, showed that many patients with lumbar disc herniation would improve without surgical intervention. In the ensuing decades, the debate over operative indications and timing continued, reaching another pivotal moment with the 2006 publication of the initial results of Spine Patient Outcomes Research Trial.

[Sciatica. From stretch rack to microdiscectomy]. / Ischias. Von der Streckbank zur Mikrodiskektomie.

In ancient times as well as in the Middle Ages treatment options for discogenic nerve compression syndrome were limited and usually not very specific because of low anatomical and pathophysiological knowledge. The stretch rack (scamnum Hippocratis) was particularly prominent but was widely used as a therapeutic device for very different spinal disorders. Since the beginning of the nineteenth century anatomical knowledge increased and the advances in the fields of asepsis, anesthesia and surgery resulted in an increase in surgical interventions on the spine. In 1908 the first successful lumbar discectomy was initiated and performed by the German neurologist Heinrich O. Oppenheim (1858-1919) and the surgeon Fedor Krause (1857-1937); however, neither recognized the true pathological condition of discogenic nerve compression syndrome. With the landmark report in the New England Journal of Medicine in 1934, the two American surgeons William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963) finally clarified the pathomechanism of lumbar disc herniation and furthermore, propagated discectomy as the standard therapy. Since then interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. The surgical procedures changed over time and were continuously being refined. In the late 1960s the surgical microscope was introduced for spinal surgery by the work of the famous neurosurgeon Mahmut Gazi Yasargil and his colleague Wolfhard Caspar and so-called microdiscectomy was introduced. Besides open discectomy other interventional techniques were developed to overcome the side effects of surgical procedures. In 1964 the American orthopedic surgeon Lyman Smith (1912-1991) introduced chemonucleolysis, a minimally invasive technique consisting only of a cannula and the proteolytic enzyme chymopapain, which is injected into the disc compartment to dissolve the displaced disc material. In 1975 the Japanese orthopedic surgeon Sadahisa Hijikata described percutaneous discectomy for the first time, which was a further minimally invasive surgical technique. Further variants of minimally invasive surgical procedures, such as percutaneous laser discectomy in 1986 and percutaneous endoscopic microdiscectomy in 1997, were also introduced; however, open discectomy, especially microdiscectomy remains the therapeutic gold standard for lumbar disc herniation.

Overview of disc arthroplasty-past, present and future.

Degenerative disc disease is one of the most frequent spinal disorders. The anatomy and the biomechanics of the intervertebral disc are very complex, and the pathomechanics of its degeneration are poorly understood. Despite this complexity and uncertainty, great advances have been made in the field of disc replacement technology, with promising results. Difficulties are continuously being encountered, but careful analysis of the results and intensive research and development will assist in countering these problems. There are approximately 40 clinical reports in the literature describing various aspects of randomised controlled trials involving intervertebral disc arthroplasty. However, the majority of these publications do not provide reliable information, in that they give only interim results and/or the results from just one of the many centres in multicentre studies. Such publications must be interpreted with caution, since they do not always represent the results of the whole study population and may hence be underpowered. We identified six randomised controlled trials that compared the final clinical outcomes of disc arthroplasty and spinal fusion. The present systematic review attempts to give an overview of the current status of disc arthroplasty.

Right Versus Left Approach to Anterior Cervical Discectomy and Fusion: An Anatomic Versus Historic Debate.

The debate over the influence approach sidedness has on the risk of recurrent laryngeal nerve palsy (RLNP) following anterior cervical discectomy and fusion (ACDF) has its origins with the introduction of the procedure for radicular pain in the 1950s. The recurrent laryngeal nerves follow disparate courses in the lower neck secondary to differences in embryogenesis. Because of these differences, some authors believe a right-sided approach increases the risk of RLNP. However, modern surgical series have not shown a clear risk of RLNP with a right- versus left-sided approach. By looking at the historical context surrounding the introduction of ACDF, we propose the dogmatic view of an increased risk of RLNP with a right-sided approach likely arose from a combination of theoretical anatomic risk and the early surgical experience of a pioneer of the procedure.

Albert Dereymaeker and Joseph Cyriel Mulier's description of anterior cervical discectomy with fusion in 1955.

Anterior cervical discectomy with fusion (ACDF) is a very well-known and often-performed procedure in the practice of spine surgeons. The earliest descriptions of the technique have always been attributed to Cloward, Smith, and Robinson. However, in the French literature, this procedure was also described by others during the exact same time period (in the 1950s). At a meeting in Paris in 1955, Belgians Albert Dereymaeker and Joseph Cyriel Mulier, a neurosurgeon and an orthopedic surgeon, respectively, described the technique that involved an anterior cervical discectomy and the placement of an iliac crest graft in the intervertebral disc space. In 1956, a summary of their oral presentation was published, and a subsequent paper-an illustrated description of the technique and the details of a larger case series with a 3.5-year follow-up period-followed in 1958. The list of authors who first described ACDF should be completed by adding Dereymaeker's and Mulier's names. They made an important contribution to the practice of spinal surgery that was not generally known because they published in French.

How a Lumbar Diskectomy Influenced Medical Malpractice and the Landscape of Health Care.

BACKGROUND: Jeff Chandler was one of Hollywood's top leading men in the 1950s and 1960s. In 1961, at the peak of his career, Chandler died of complications following an aortic-iliac injury during a routine lumbar diskectomy. The subsequent public outcry and malpractice suit resulted in an unprecedented settlement award. CASE: Chandler's lawsuit marked a pivotal time in the evolution of medical malpractice and monetary awards. Before 1960, malpractice legal claims were rare, with little impact on the practice of medicine. Chandler's award, however, dwarfed the average malpractice verdict for its time and would influence the relationship between medicine and the legal world. This case helped issue a radical increase in total expenditure on medical liability insurance, frequency of successful claims, average numbers of neurosurgical malpractice suits, and financial award sizes. The trend ensuing from this time has continued to the contemporary era. To link Chandler's case to the current malpractice climate, we highlight the relationship of the case with 3 factors comprising the legal argument for the perpetuation of medical malpractice: 1) contingency fees, 2) citizen juries, and 3) the nature of tort law. CONCLUSION: This case illustrates an inflection point in American medical malpractice expenditure increases beginning in the 1960s to a current estimated $55.6 billion. As we investigate ways to provide value in health care, it is important to consider the historical factors that have influenced the status quo when seeking strategies to reform the malpractice system on both sides of the value equation: quality and cost.

Ralph Bingham Cloward (1908-2000): Spine Polymath.

Dr. Ralph Bingham Cloward, an American neurosurgeon, revolutionized the field of modern spine surgery with his lifelong innovative and pioneering contribution. He described the posterior lumbar interbody fusion and anterior cervical discectomy and fusion. He engineered more than 100 instruments, which shared his intellect and wisdom to the neurosurgery and orthopedic fraternity across the globe. He was also the first person to set up a bone bank in the United States. He rightfully deserves the title "Michelangelo of neurosurgery" for his exceptional work.

History of surgery for ruptured disk.

The history of surgery for ruptured disk of the human spine began approximately a century ago. Advances in the understanding of symptoms and signs of root or cord compression, their relationship to the pathology, and the refinement in imaging techniques have contributed to the present surgical management of rupture disk disease. Historical findings relevant to the cervical, thoracic, and lumbosacral regions of the spine, with relevant pathophysiology, imaging, and surgical treatment, including the evolution of various surgical approaches are discussed. Surgeons and other contributors in the medical field are cited for their respective contributions to the evolution of the present operative approaches for disk ruptures in the cervical, thoracic, and lumbar spinal regions.

The "tract" of history in the treatment of lumbar degenerative disc disease.

In this paper past, present, and future treatments of degenerative disc disease (DDD) of the lumbar spine are outlined in a straight forward manner. This is done to review previous knowledge of the disease, define current treatment procedures, and discuss future perspectives. An analysis of a subject of this magnitude dictates that one describes as accurate a history as possible: an anatomical/historical "tract" with emphasis on all possible deviations. Although spinal disorders have been recognized for a long time, the view of DDD as a particular disease entity is a more recent development. In this paper, the authors attempt to outline the history of DDD of the lumbar spine in an unbiased and scientific fashion. Physiological, diagnostic, and therapeutic implications will all be addressed in this study.

Minimally invasive spinal surgery: a historical perspective.

The concept of minimally invasive spinal surgery embodies the goal of achieving clinical outcomes comparable to those of conventional open surgery, while minimizing the risk of iatrogenic injury that may be incurred during the exposure process. The development of microscopy, laser technology, endoscopy, and video and image guidance systems provided the foundation on which minimally invasive spinal surgery is based. Minimally invasive treatments have been undertaken in all areas of the spinal axis since the 20th century. Lumbar disc disease has been treated using chemonucleolysis, percutaneous discectomy, laser discectomy, intradiscal thermoablation, and minimally invasive microdiscectomy techniques. The initial use of thoracoscopy for thoracic discs and tumor biopsies has expanded to include deformity correction, sympathectomy, vertebrectomy with reconstruction and instrumentation, and resection of paraspinal neurogenic tumors. Laparoscopic techniques, such as those used for appendectomy or cholecystectomy by general surgeons, have evolved into procedures performed by spinal surgeons for anterior lumbar discectomy and fusion. Image-guided systems have been adapted to facilitate pedicle screw placement with increased accuracy. Over the past decade, minimally invasive treatment of cervical spinal disorders has become feasible by applying technologies similar to those developed for the thoracic and lumbar spine. Endoscope-assisted transoral surgery, cervical laminectomy, discectomy, and foraminotomy all represent the continual evolution of minimally invasive spinal surgery. Further improvement in optics and imaging resources, development of biological agents, and introduction of instrumentation systems designed for minimally invasive procedures will inevitably lead to further applications in minimally invasive spine surgery.

Tratamiento de la discopatía cervical: evidencia válida 50 años después / Cervical disk treatment: valid evidence 50 years after

Se comenta una revisión sistemática sobre el estado actual de la cirugía anterior del disco cervical. Los autores de la revisión trataron de determinar que método de artrodesis intersomática cervical anterior, para uno o dos niveles, tuvo la mejor evolución clínico-radiológica en pacientes con enfermedad degenerativa discal. Sólo incluyeron estudios prospectivos, aleatorizados y controlados que comparaban deversas técnicas de discectomía, artrodesis e instrumentación. Surgió de la revisión, que las evidencias disponibles para tomar una decisión terapéutica valida, en el empleo de las diferentes técnicas, fueron débiles como consecuencia de la baja calidad metodológica de los estudios en el análisis. Palabras clave: artrodesis cervical anterior - discectomía cervical anterior - instrumentación - revisión sistemática(AU)

A systematic review about the current state anterior cervical disc surgery was commented. The authors of this review tried to determine which method of anterior cervical interbody fusion at one or two-levels provided the best clinical and radiological outcome in patients with degenerative disc disease. They only included prospective, randomized and controlled studies that compared several techniques of discectomy. fusion and isntrumentation. The review showed that at most trials analyzed were of low quality the evidences available to sustain a valid therapoeutic intervention were weak. Key words: anterior cervical discectomy, anterior cervical fusion, intrumentation, systematic review.

Tratamiento de la discopatía cervical: evidencia válida 50 años después / Cervical disk treatment: valid evidence 50 years after

Se comenta una revisión sistemática sobre el estado actual de la cirugía anterior del disco cervical. Los autores de la revisión trataron de determinar que método de artrodesis intersomática cervical anterior, para uno o dos niveles, tuvo la mejor evolución clínico-radiológica en pacientes con enfermedad degenerativa discal. Sólo incluyeron estudios prospectivos, aleatorizados y controlados que comparaban deversas técnicas de discectomía, artrodesis e instrumentación. Surgió de la revisión, que las evidencias disponibles para tomar una decisión terapéutica valida, en el empleo de las diferentes técnicas, fueron débiles como consecuencia de la baja calidad metodológica de los estudios en el análisis. Palabras clave: artrodesis cervical anterior - discectomía cervical anterior - instrumentación - revisión sistemática(AU)

A systematic review about the current state anterior cervical disc surgery was commented. The authors of this review tried to determine which method of anterior cervical interbody fusion at one or two-levels provided the best clinical and radiological outcome in patients with degenerative disc disease. They only included prospective, randomized and controlled studies that compared several techniques of discectomy. fusion and isntrumentation. The review showed that at most trials analyzed were of low quality the evidences available to sustain a valid therapoeutic intervention were weak. Key words: anterior cervical discectomy, anterior cervical fusion, intrumentation, systematic review.

Tratamiento de la discopatía cervical: evidencia válida 50 años después / Cervical disk treatment: valid evidence 50 years after

Se comenta una revisión sistemática sobre el estado actual de la cirugía anterior del disco cervical. Los autores de la revisión trataron de determinar que método de artrodesis intersomática cervical anterior, para uno o dos niveles, tuvo la mejor evolución clínico-radiológica en pacientes con enfermedad degenerativa discal. Sólo incluyeron estudios prospectivos, aleatorizados y controlados que comparaban deversas técnicas de discectomía, artrodesis e instrumentación. Surgió de la revisión, que las evidencias disponibles para tomar una decisión terapéutica valida, en el empleo de las diferentes técnicas, fueron débiles como consecuencia de la baja calidad metodológica de los estudios en el análisis. Palabras clave: artrodesis cervical anterior - discectomía cervical anterior - instrumentación - revisión sistemática

A systematic review about the current state anterior cervical disc surgery was commented. The authors of this review tried to determine which method of anterior cervical interbody fusion at one or two-levels provided the best clinical and radiological outcome in patients with degenerative disc disease. They only included prospective, randomized and controlled studies that compared several techniques of discectomy. fusion and isntrumentation. The review showed that at most trials analyzed were of low quality the evidences available to sustain a valid therapoeutic intervention were weak. Key words: anterior cervical discectomy, anterior cervical fusion, intrumentation, systematic review.